I used to run outreach and public education for the Affordable Care Act marketplaces. So I have a very good sense of what the Trump administration’s decision to cut funding for advertising and in-person assistance will do to enrollment.
The Trump administration announced a couple of weeks ago that the advertising budget for this year’s open enrollment period for the ACA marketplace would be cut by 90 percent (from $100 million to $10 million), and that it was cutting in-person assistance through its “navigator” grants by 40 percent (from $63 million to $37 million).
This is nothing less than sabotage. “The best thing we can do politically speaking is let Obamacare explode,” Trump has said. “It is exploding right now.” In fact, it is not “exploding.” But few things make this more likely than skimping on efforts to encourage people to sign up for coverage at Healthcare.gov, and to make it harder for them to get their questions about the program answered.
One source at Health and Human Services dismissed news of the outreach cuts by saying (courageously, on background), “most Americans are aware of the program at this point in time.” But anyone who has worked on health care enrollment knows that’s a complete joke.
Vague awareness that the ACA exists is a lot different from knowing how to enroll
The truth is that most people don’t know the open enrollment dates, and they don’t know that the deadline this year is December 15 — not January 31, like last year. They don’t know that by shopping on Healthcare.gov they are likely to find a plan that costs less than a $100 a month. I know this, because my office produced reams of data that proved the overall effectiveness of outreach advertising.
Signing up for health care is a big decision, especially for those who have never had health insurance. People think it’s out of reach, that they can’t afford it, that it’s just too difficult — or they’re young and healthy, so why bother? And the ongoing public debate about repeal has only added to the confusion. So it’s no surprise some people will throw up their hands and roll the dice, betting they won’t getting too sick or too injured.
Advertising, backed up by an informative website and in-person assistance, can help people grasp that health coverage under the ACA may be more affordable than they think, leading them to sign up.
Those of us who promoted the ACA were committed to getting the most out of every dollar. We had a lot of channels we could use: TV, radio, digital advertising, outdoor advertising, plus more-direct communications such as email, text messaging and phone calls. We set up randomized control trials and econometric modeling to test all of these paid outreach options against each other.
TV ads, we learned, were the most cost-effective way to encourage enrollment
I started in my position right before the second open enrollment period for the ACA, and our study of outreach outcomes was in full swing by the third enrollment period, in 2015. Despite our preconceived notion that digital media might deliver the biggest bang for our buck, we found that TV still was the number one driver of enrollment. Not only that, but TV ads acted as a sort of multiplier — magnifying the effects of every dollar spent on digital, email, and everything else. Taken together, we found, paid outreach was directly responsible for about 40 percent of all enrollments.
That’s why the decision to cut the outreach and advertising budget by 90 percent, including zeroing out spending on TV advertising, is so dumbfounding (unless the goal is to undermine the program). Look at what happened in Kentucky when the state completely cut its TV advertising. An academic study found that the state’s enrollment site, Kynect, got 450,000 fewer page views and 20,000 fewer unique visitors each week. The fewer the people who are shopping and looking for coverage, the fewer the people who end up enrolling.
Unsurprisingly, in Kentucky enrollment in the ACA marketplaces dropped from 106,300 in 2015 to 81,200 in 2017.
So when you hear an unnamed administration spokesperson try to spin their decision to cut advertising as a way of improving efficiency, or as unnecessary because everyone knows about Obamacare, know this: They are lying. They have the evidence from the previous open enrollments. They have the consumer research and the data from all of the testing. And they tossed it out the window.
With the new open enrollment season imminent, Trump has thrown community-based health care “navigators” into chaos
We also know that the in-person navigator programs — also gutted by Trump — are effective. Under the navigator programs, local community-oriented organizations help people sign up for health care by holding enrollment events where people can drop by to find out more. (Or they can schedule appointments.)
The plans of community-based “navigators” have been thrown into chaos, hurting people who need their advice.
When we chose the recipients of the first of the three-year grants to support navigator work, in 2015, a priority was to fund groups working in underserved communities or with more vulnerable populations. Think rural areas or people with disabilities or people with very specific health needs or immigrant communities. Those nonprofits that received a navigator grant are long-standing organizations entrenched in their communities. They’re not new or political; they’re just trying to help their neighbors get the care they need.
Back in 2016, the funding was set at $67 million; the following year it was $63 million. Many navigators were assured by the current administration that they didn’t need to worry about funding for this year — that it would be on par with previous years. Plans were made, staff hired. But instead of using the criteria used to judge grant levels in the past, the administration changed the rules at the end of the game. The new rules cut the funding if navigators are falling short of the goal they had set for themselves.
Here’s the problem with that approach: Since people didn’t know this would happen, they may have set very high aspirational goals. Now people who set ambitious plans are punished.
It’s still unclear how the cuts will play out: With open enrollment less than two months away (it starts November 1), navigators know only that they will have to cut expenses and lay off staff.
Who will pay the price for the administration’s last-minute decision to cut navigator funding by 40 percent? The people who need that help the most. A study by the Kaiser Family Foundation found that about 80 percent of people sought in-person assistance because they “lacked the confidence to apply on their own.” About a third lacked access to the internet, while some 18 percent needed translation help.
An analysis by Enroll America after the first open enrollment found that African Americans and Latinos were 43 percent more likely to seek help through in-person assistance than white people.
There is no question: If people don’t get the help they need to enroll, if there is any sort of barrier put in front of them, if they don’t have the information they need, they won’t enroll. This is not conjecture. These are facts.
Advertising is key to attracting the healthy people the system needs
And it’s not only that fewer people sign up from underserved communities. Advertising, especially, is crucial to getting healthier and younger people to sign up for health care. And these young and healthy people are crucial for strong and stable exchanges. Because of the decisions made by the Trump administration, there will be fewer healthy people in the markets, and that means premiums will go up.
We should not be surprised by the administration’s actions, appalling as they are. On his first day in office, Trump issued an executive order demanding federal agencies to do the maximum allowed under law to dismantle the ACA. Then, ahead of the final week of open enrollment for coverage in 2017 — right after Trump became president — the administration slashed the television budget, which probably meant about 500,000 fewer people ended up signing up for health care. (That cut was separate from the TV cuts this year.)
And then, as mentioned above, the administration cut in half the number of days people have to sign up for coverage, from 90 days to only 45.
The Trump administration’s recent decisions show just how far they are willing to go to undermine a program they hate but can’t find the political support for repealing. If Congress won’t do away with the ACA, Trump officials will do what they can to make it fail themselves, damn the consequences to people’s lives. And never mind that HHS Secretary Tom Price is legally obliged to support the law as it stands.
Price likes to say that Obamacare is in a “death spiral.” The problem is that now it’s in his power to make his wishes come true, by keeping people from getting the health care information they so badly need.
Lori Lodes is the former director of the office of communications for the Centers for Medicare & Medicaid Services. Find her on Twitter @loril.
The Big Idea is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at firstname.lastname@example.org.